More than 200 children with autism who received a special, but expensive, form of treatment under the popular state-subsidized Healthy Families insurance program are finding the Medi-Cal managed care program they were transferred to beginning in January doesn’t cover it. 

When California began moving 880,000 children from Healthy Families to save money and allegedly provide better, more coordinated care, parents of children who received Applied Behavior Analysis (ABA) were told insurance coverage would continue. According to autism advocate Laura Shumaker, families were notified in writing that, “Your child will continue to have all of the same services during this move. Your child’s coverage will not be interrupted.”  

Turns out, that is not the case.

Back in April, Kathy Robertson at the Sacramento Business Journal wrote that families whose kids had lost coverage were pleading with lawmakers for help. State senators added $50 million to a budget bill to provide funding for the treatment, but it was dropped at a later stage.

Legislators passed a law that took effect last July to compel private insurers to cover the therapy, but specifically excluded Medi-Cal. Without insurance coverage, low-income folks on Medi-Cal cannot possibly afford the costs, which can run $100,000 a year.

There are ways around the prohibition for some children. Developmentally disabled kids who have access to regional centers can fight for some of the limited available slots and receive treatment there.       

There is some evidence that even families with private insurance are not guaranteed coverage for the therapy. The Los Angeles Times reported in February that state Insurance Commissioner Dave Jones had received dozens of complaints that insurance companies were delaying and denying coverage.

The commissioner told the Times, “Behavioral therapy is a medical treatment and has to be covered.”

But insurance companies saw it differently. “The science continues to evolve,” argued Richard Wiebe, a spokesman for the Association of California Life and Health Insurance Companies. “The regulations should . . . let that evolution take place.”  

Autism is a complex developmental disorder marked by impaired social interaction and restricted, repetitive behavior. There are no medical tests for definitively identifying autism, the causes are still under debate and treatment is varied and still developing.

The U.S. Centers for Disease Control and Prevention reported that 1 in 88 American children were on the autism spectrum as of 2012, a 10-fold increase since 1972.

–Ken Broder

To Learn More:

On Autism, State Won’t Follow Its Own Edict (by Daniel Weintraub, HealthyCal)

Autism in California: Trouble in Insurance-Land (by Laura Shumaker, San Francisco Chronicle)

Some Autistic Children Left out in Medi-Cal Transition (by Kathy Robertson, Sacramento Business Journal)

Insurers Not Covering Behavioral Therapies for Autism, California Says (by Alan Zarembo, Los Angeles Times)

Putting the Pieces Together (California Autism Foundation)